Try using the Question And Answer option on registrations.
Ask several questions that only legitimate humans knowledgeable about your specific forum topic can answer and do not ask "yes" or "no" questions or anything that is a 50/50 answer like "true" or "false."
Spam-O-Matic is incredibly outdated and doesn't actually stop spam any longer so far as I can tell. Do you have the Stop Forum Spam set up to check IP addresses and e-mail addresses? You could set it to check user names but that gives false positives.
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